Where should transcatheter aortic valve implantation go beyond 2012?
Department of Cardiology, Kings College Hospital, Kings Health Partners, London, UK.Journal of Cardiovascular Medicine (Impact Factor: 1.51). 05/2012; 13(8):516-23. DOI: 10.2459/JCM.0b013e328354cdac
Although surgical aortic valve replacement (sAVR) remains the gold standard treatment for severe, symptomatic aortic stenosis in a low-risk population, the role of transcatheter aortic valve implantation (TAVI) has increased significantly in the past decade and has entered the 'clinical mainstream' for the treatment of high-risk, inoperable patients. The transcatheter technique has evolved and improved immeasurably since its introduction some years ago. Not only is valve design evolving, but access site, size/technology of delivery systems and procedural technique are also undergoing continuous refinement. New devices are now available to prevent complications such as cerebral embolization, and occlusion balloons and covered stents are used to manage vascular complications more expertly. Early experiences are being gained in the treatment of failing bioprostheses - so-called 'valve-in-valve' therapy, even in the mitral position. In this article, we discuss the new transcatheter alternatives to open heart valve surgery and review the most recent clinical evidence and the currently available and emerging technology in transcatheter treatment.
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ABSTRACT: Transcatheter aortic valve replacement (TAVR) is entering its second decade. Three major clinical challenges have emerged from the first decade of experience: vascular complications, stroke, and paravalvular leak (PVL). Major vascular complications remain common and independently predict major bleeding, transfusion, renal failure, and mortality. Although women are more prone to vascular complications, overall they have better survival than men. Further predictors of major vascular complications include heavily diseased femoral arteries and operator experience. Strategies to minimize vascular complications include a multimodal approach and sleeker delivery systems. Although cerebral embolism is very common during TAVR, it mostly is asymptomatic. Major stroke independently predicts prolonged recovery and increased mortality. Identified stroke predictors include functional disability, previous stroke, a transapical approach, and atrial fibrillation. Embolic protection devices are in development to mitigate the risk of embolic stroke after TAVR. PVL is common and significantly decreases survival. Undersizing of the valve prosthesis can be minimized with 3-dimensional imaging by computed tomography or echocardiography to describe the elliptic aortic annulus accurately. The formal grading of PVL severity in TAVR is based on its percentage of the circumferential extent of the aortic valve annulus. Further emerging management strategies for PVL include a repositionable valve prosthesis and transcatheter plugging. The first decade of TAVR has ushered in a new paradigm for the multidisciplinary management of valvular heart disease. The second decade likely will build on this wave of initial success with further significant innovations.
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ABSTRACT: The study sought to contrast risk profiles and compare outcomes of patients with severe aortic stenosis (AS) and coronary artery disease (CAD) who underwent aortic valve replacement (AVR) and coronary artery bypass grafting (AS+CABG) with those of patients with isolated AS who underwent AVR alone. In patients with severe AS, CAD is often an incidental finding with underappreciated survival implications. From October 1991 to July 2010, 2,286 patients underwent AVR+CABG and 1,637 AVR alone. A propensity score was developed and used for matched comparisons of outcomes (1,082 patient pairs). Analyses of long-term mortality were performed for each group, then combined to identify common and unique risk factors. Patients with AS+CAD versus isolated AS were older, more symptomatic, and more likely to be hypertensive, and had lower ejection fraction and greater arteriosclerotic burden but less severe AS. Hospital morbidity and long-term survival were poorer (43% vs. 59% at 10 years). Both groups shared many mortality risk factors; however, early risk among AS+CAD patients reflected effects of CAD; late risk reflected diastolic left ventricular dysfunction expressed as ventricular hypertrophy and left atrial enlargement. Patients with isolated AS and few comorbidities had the best outcome, those with CAD without myocardial damage had intermediate outcome equivalent to propensity-matched isolated AS patients, and those with CAD, myocardial damage, and advanced comorbidities had the worst outcome. Cardiovascular risk factors and comorbidities must be considered in managing patients with severe AS. Patients with severe AS and CAD risk factors should undergo early diagnostics and AVR+CABG before ischemic myocardial damage occurs.
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